Urology/Kidney stones or Prostatic varices

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Expert: Arthur Goldstein, M.D. - 4/5/2013

Question"I am a 62 year old man, I take Lipitor, 20mg daily. I had a vasectomy about 25 years ago, and over the past 20 years have had periods of prostatitis-like symptoms of burning, discomfort, etc. I typically get up once during the night to urinate. My recent DRE showed an enlarged prostate – noticeably larger than previous exams - with no masses, thickening or asymmetries. My PSA is 0.17 which is about what it’s always been. I frequently experience some degree of burning when I urinate.

Sporadically over the past 10 years or so (once every couple of years) I’ve had symptoms where I see bright red blood drops always at the end of urination. When these episodes occur, it usually begins with a very intense needle-like pain at the tip of the penis at or near the start of that urination. The blood is usually present in a few following urinations- always at the end - but the entire episode generally clears up within 12 -24 hours or so. Sometimes I only see the dried blood drops in my underwear. Urine tests following these episodes are always negative for blood and bacteria. Recently, these episodes have occurred more frequently, several times in the past nine months.

I’ve always thought small kidney stones have been responsible because of the very sharp penile pain at the start. After the most recent occurrence, I had a CT scan.which showed no evidence of stones. The kidneys were normal, there was no renal enlargement or masses, the ureters and bladder were ‘unremarkable’ and there was no evidence of urolithiasis. Recently I read your response to another writer about prostatic varices. Those symptoms seem very much like my own. Do you think my problem is more likely prostatic varices? Is there some way I can prevent future occurrences?

Thank you very much,
Rob"

AnswerRob, you apparently have read some of my consults in the past. It sounds like you have a combination of prostatitis, & prostatic varices as well as underlying BPH. Before giving my recommendations, just for the sake of completeness, I am now going to attach my "macros" on the first 2 conditions. If you also wish to receive my "macro" on BPH, let m know.

PROSTATITIS: Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, urethral discharge, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – between the “wind and the rain”) and constipation. The passage of blood at the initiation or termination of urination or in the semen can also be noted. During sexual arousal the prostate gland & seminal vesicles manufacture fluid that account for the majority of the semen. The seminal vesicles are paired structures located behind the prostate gland that are also sensitive to sexual excitement. Sperm from the testicles (which account for only 1-2 % of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts. These structures empty into the prostatic portion of the urethra. At the time of ejaculation, fluid is discharged from the prostate gland and ejaculatory ducts into the urethra (urinary canal) forming the semen. The average semen volume is 2-6 cc. With the inception of ejaculation, the bladder neck closes and the semen is forced forward out the urethra by contraction of the pelvic muscles.

It is not uncommon for inflammation and/or infection to spread in a retrograde manner into the vas and epididymis. Even without such spread, prostatic discomfort is often referred into the testicle. Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this. Sitting for long periods of time, especially in an automotive vehicle, can put undo pressure on the prostate and aggravate the condition. For the latter, it is best not to sit more than 2-3 hours at a time. Stop the vehicle periodically, take a short walk and go to the bathroom to urinate. A thick pad or piece of sponge rubber on your seat will also help to cushion the prostate. One should avoid any of the above that apply. Eliminating all of these factors that apply to you are just as important, if not more so, than taking medication! Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort. Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms. For most men, ejaculation in moderation, perhaps 1-2 times a week, is reasonable. A daily warm bath for 10-15 minutes 1-2 times daily also lessens the discomfort. Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed.

There are several types of prostatitis. Sometimes prostatitis can be due to an infection of the gland with bacteria. Typically, pus cells and bacteria are found in the prostatic fluid. The infection usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work).

Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria. In the other, there are neither pus cells nor bacteria in the fluid, just the symptoms. In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder. Abacterial prostatitis is an elusive entity that has been called by a variety of names including nonbacterial prostatitis, prostadynia, pelvic congestion syndrome and most recently pelvic myoneuropathy. The latter name was coined by Dr. David Wise of Stanford. He believes that this may represent up to 95% of all cases of prostatitis. This variant may be an expression of interstitial cystitis and possibly is due to autoimmune or neurogenic factors. Dr. Wise suggests that the primary cause of the symptoms involves pelvic muscle spasm, nerve trigger points and some degree of anxiety (either the cause or result of the symptoms). His therapy involves the use of anti-depressents (we have used Elavil for years in refractory patients), relaxation techniques, trigger point physiotherapy, and biofeedback. Some others recommend Yoga & meditation as being useful. Although he may well prove to be correct, I generally recommend an initial course of antibacterial therapy for patients who clinically have symptomatic prostatitis of any variety. The majority of patients (even those with nonbacterial prostatitis) seem to respond favorably. It has been know for decades that many patients with the abacterial variety of prostatitis do well with antibiotics but the reason has been vague. Some theorized that they may harbor bacteria in the tissues of the prostate that are not being picked up in cultures (possibly walled off loci of infection). For more information on Dr. Wise's studies check out:http://www.pelvicpainhelp.com /

In my experience, symptoms usually responds to the general measures mentioned in the initial paragraph. Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha-blockers (such as Flomax, Hytrin, Cardura & Uroxatral). The latter require a prescription from you physician if he thinks it is indicated. More recently, a naturally occurring flavinoid with anti-oxidant and anti-inflammatory properties (such as quercetin) has been used in prostatitis. It's success is yet to be confirmed.

Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic. It may also occur as a single episode, be recurrent or chronic. In chronic bacterial prostatitis, long term low dose antibacterial therapy often works well in suppressing symptoms. In refractory cases, culture of the prostatic fluid or semen often will disclose the offending bacteria. If found, sensitivity studies can identify which antibiotics are most likely to eliminate that particular germ. One should be off of all antibiotics for 7-10 days before the culture is taken. Otherwise, if there is residual antibiotics in your system, this may prevent bacteria from growing in culture.

In other cases refractory to treatment, there is another condition that can produce similar symptoms. This disorder is ejaculatory duct obstruction. Usually the doctor will find the seminal vesicles to be very swollen on rectal examination. The patient will notice either absence or a markedly diminished semen volume. The diagnosis is made by doing a transrectal ultrasound of the prostate and seminal vesicles.

Therefore, if symptoms persist, consultation with a urologist should be scheduled. In cases with recurrent prostatitis or hematuria, it often is necessary to study the urinary tract more completely. Predisposing factors to prostatitis such as a urethral stricture (narrowing) and other disorders can then be evaluated. A man should learn to listen to his body.

PROSTATE BLEEDING: Your type of bleeding usually comes from the prostate gland. It is generally due to a tear in one of the fragile veins of the prostate gland or an inflammation of the prostate (prostatitis). Bleeding may occur during sexual excitation, ejaculation, from straining with bowel movements, or during urination. The prostate is the organ that produces the majority of the seminal fluid in response to sexual stimulation. When the prostate contracts at the time of ejaculation, a vein may tear and blood mixes with the semen (hematospermia). Red blood indicates new and dark (brownish) discoloration indicates previous bleeding.

In addition, prostatic bleeding frequently is associated with gross blood during urination. This typically will occur with initiation or at the end of urination (as opposed to being throughout the entire stream). With the latter, it is often manifest as spots of blood on the underwear, pajamas or bed sheets. Irritation of the gland (prostatitis) can also cause it to become inflamed and predisposed to bleed. An inflamed or congested prostate gland, especially one with varices, can start bleeding if ones strains during a bowel movement. This occurs because hard stool can actually push on the adjacent gland precipitating bleeding or straining in itself may cause the varices to rupture. Some factors leading to inflammation include too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, excessive alcohol or spicy foods, prolonged sitting or bike riding, etc. The prostate may then become secondarily infected and require antibiotic therapy for cure. Sometimes as the prostate gradually enlarges with age, friable veins called varices develop on its surface. These are also prone to tearing. In such cases, Proscar or Avodart is sometimes prescribed to shrink both the prostate and the veins. These are not generally recommended in men less than 40-50 years of age. Although hematospermia is not a typical sign of prostate cancer, its presence may indicate an increased risk of prostate cancer. Therefore, it is advisable to seek consultation with a urologist to evaluate this condition.

As far as treating your present symptoms are concerned, since the bleeding is probably due to protatitis and/or varices, either a course of antibiotics for the prostatitis (such as one of the fluoroquinolones) and/or long term treatment with Proscar (or Avodart) to shrink the prostate and accompanying varices seems indicated. This, of course, should be orchestrated through your urologist. Good luck.